Palliative care interventions in chronic respiratory diseases: A systematic review.

INTRODUCTION: Chronic respiratory diseases represent a significant burden of disease globally, with high morbidity and mortality. Individuals living with these conditions, as well as their families, face considerable physical, emotional and social challenges. Palliative care might be a valuable approach to address their complex needs, but evidence to prove this is still scarce. OBJECTIVES: This systematic review aimed to study the effectiveness of palliative care interventions in health-related outcomes (quality of life, symptom control, symptom burden, psychological well-being, advance care planning, use of health services, and survival) in chronic respiratory patients. METHODS: Pubmed, Cochrane and Web of Science were searched for trials published in the last 10 years, comparing palliative care interventions to usual care, in patients with chronic respiratory diseases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS: Eight studies were included, seven randomized controlled trials and one cluster-controlled trial; the former with moderate risk of bias and the latter with high risk of bias. Findings revealed that palliative interventions improve breathlessness control and advance care planning. There were no significant differences for the other outcomes. CONCLUSIONS: Palliative care appears to have a beneficial effect on breathlessness, one of the most distressing symptoms in patients suffering from chronic respiratory diseases and allows for advanced care planning. Additional research, with more robust trials, is needed to draw further conclusions about other health-related outcomes.

Effects of cannabinoids on pain control, quality of life and opioid-sparing in cancer patients: systematic review / Utilização de canabinoides no controle da dor, na qualidade de vida e no efeito poupador de opioides em pacientes com câncer: revisão sistemática

ABSTRACT BACKGROUND AND OBJECTIVES: Cannabinoids, such as delta-9-tetrahydrocannabinol and cannabidiol, have several therapeutic properties that may be useful in medicine. The objective of this study was to analyze the impact of cannabinoid use on pain control, quality of life and opioid-sparing in patients with advanced cancer. CONTENTS: A systematic review of the evidence for the use of cannabinoids in patients with advanced cancer was conducted on 1) Pain control; 2) Quality of life; and 3) Opioid-sparing effect. PubMed, Web of Science and Cochrane databases were searched for articles, written in English, published between January 1, 2011, and December 31, 2022, with the filters "randomized controlled trials" and "clinical trials". Using oral formulations of cannabinoids was accepted as "intervention" and placebo as "control". Risk of bias analysis was performed with Cochrane's RoB 2 and ROBINS-I tools. This review followed the 2020 PRISMA- statement. Ten studies were included, with 1169 participants, most with moderate risk of bias. The studies were from Australia (n=4), Canada (n=1), Israel (n=1), Mexico (n=1), The United Kingdom (n=1); two were multinationals. Eight were randomized, placebo-controlled trials; two were non-randomized studies. The most used formulation was nabiximols oral spray. Cannabinoids provide a clinical improvement in pain control. Evidence of improved quality of life with cannabinoids is inconclusive. Cannabinoids do not affect the daily dose of opioids in refractory cancer pain. Cannabinoid use cannot be said to have an opioid-sparing effect. CONCLUSION: It is necessary to expand research on the prescription of cannabinoids in individuals with cancer and other progressive diseases, with several comorbidities and multiple medications, in different health contexts.

RESUMO JUSTIFICATIVA E OBJETIVOS: Os canabinoides, como o delta-9-tetrahidrocanabinol e o canabidiol, possuem propriedades terapêuticas que podem ser úteis em pacientes oncológicos. O objetivo deste estudo foi avaliar o impacto do uso de canabinoides no controle da dor, na melhoria da qualidade de vida, e no efeito poupador de opioides em pacientes com câncer avançado. CONTEÚDO: Realizou-se uma revisão sistemática sobre a evidência da utilização de canabinoides em pacientes com câncer avançado, relativamente a: 1) Controle da dor; 2) Qualidade de vida; e 3) Efeito poupador de opioides. Foram buscados artigos na Pubmed, Web of Science e Cochrane, em inglês, publicados entre 2011 e 2022, com os filtros "randomized controlled trials" e "clinical trials". Aceitaram-se como "intervenção" qualquer uso de formulações orais de canabinoides e como "controle" o uso de placebo. Fez-se análise de viés com as ferramentas da Cochrane RoB 2 e ROBINS-I. Seguiu-se a Declaração PRISMA 2020. Foram incluídos 10 estudos, com 1169 participantes, a maioria com risco moderado de viés. Os estudos provinham de Austrália (n=4), Canadá (n=1), Israel (n=1), México (n=1), Reino Unido (n=1); dois eram multinacionais. Oito eram ensaios randomizados controlados com placebo; dois eram não randomizados. A formulação mais usada foi spray bucal de nabiximóis. Os canabinoides proporcionam uma melhoria clínica do controle da dor. A evidência da melhoria da qualidade de vida com canabinoides é inconclusiva. Os canabinoides não afetam a dose diária de opioides na dor oncológica refratária. Não se pode afirmar que o uso de canabinoides tem um efeito poupador de opioides. CONCLUSÃO: É necessário incrementar a investigação sobre a prescrição de canabinoides em indivíduos com câncer e outras doenças progressivas, com comorbilidades e polimedicação, em diferentes contextos de saúde.

Impact of the COVID-19 pandemic on the non-cancer chronic pain and its management in the elderly / Impacto da pandemia do COVID-19 na dor crônica não oncológica e sua gestão em pessoas idosas

ABSTRACT BACKGROUND AND OBJECTIVES: Chronic non-cancer pain is considered a public health problem, affecting 37% of the Portuguese population. Pain treatment represents a fundamental human right. However, during the COVID-19 pandemic, the vast majority of these patient care services were considered non-urgent or non-emergent, and clinical appointments and treatment were postponed or un-scheduled. Imposed restrictions, such as measures to prevent a COVID-19 infection, became counterproductive with regard to the management of chronic pain. Its impact should be emphasized especially in the older population, due to the associated physical and psychological comorbidities. This study aimed to analyze the impact of the COVID-19 pandemic on the pain of older people in four aspects: i) intensity, treatment and management of pain; ii) mental health; iii) lifestyles; iv) quality of life. METHODS: Review in Pubmed, SCOPUS and SCIELO databases using the terms: chronic non-cancer pain, pain management, aged and COVID-19. 86 articles were found and 13 were selected. Articles included cumulatively addressed chronic pain, represented original research of a clinical nature, and analyzed the impact of the COVID-19 pandemic on the management of chronic pain. Preference was given to studies with participants aged 65 years or older. Studies in adults with no mention of age in the context of the COVID-19 pandemic impact on aspects infuencing chronic pain and its management were also included. Only one article exclusively studied the senior population. RESULTS: The pandemic affected: i) increased pain intensity (n=10), changes in its pharmacological and non-pharmacological treatment (n=3) and its management, that is, the adaption of the health professionals and patients (n=1); ii) negatively affected mental health: symptoms of stress and anxiety/depression (n=9), psychological distress (n=4), social isolation/loneliness (n=6); iii) lifestyles: physical activity (n=4), sleep quality (n=4) and physical performance (n=5); iv) reduction of quality of life (n=5). Despite the heterogeneous results, a worsening of pain and mental health was found, as well as alteration of styles and quality of life and disruption of medical services. CONCLUSION: The restrictions imposed by the pandemic affected several areas of pain in the short term. Telemedicine has emerged as an adopted solution, but the barriers in the senior population, such as lack of digital literacy and lack of technological equipment, cannot be overlooked. The lack of knowledge of the specific impact of COVID-19 on the pain of the senior population calls for more research that focuses on the long-term consequences, as well as the solutions to be adopted in order to contain the damage in this vulnerable population. HIGHLIGHTS Worsening of pain and mental health, change in lifestyles and decreased quality of life. Disruption of medical services generated by the pandemic period reinforce the need for a holistic and individual approach to health care. Impact of the pandemic on chronic pain management has been little explored in older people. Need for further research focusing on long-term consequences, as well as the solutions to be adopted in order to contain injuries or dysfunctions in this vulnerable population.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor crônica não oncológica é considerada um problema de saúde pública, afetando 37% da população portuguesa. O tratamento da dor representa um direito humano fundamental. Entretanto, durante a pandemia do COVID-19, a grande maioria destes serviços de assistência ao paciente foi considerada como não urgente ou não emergente, sendo consultas e tratamentos clínicos adiados ou desmarcados. Restrições impostas, como medidas de prevenção da infecção por COVID-19, tornaram-se contraproducentes no que se refere à gestão da dor crônica. O seu impacto deve ser realçado principalmente na população mais idosa, devido às comorbidades associadas quer físicas quer psicológicas. O objetivo deste estudo foi analisar o impacto da pandemia do COVID-19 na dor de pessoas idosas em quatro aspectos: i) intensidade, tratamento e gestão da dor; ii) saúde mental; iii) estilo de vida; iv) qualidade de vida. MÉTODOS: Revisão nas bases de dados Pubmed, SCOPUS e Scielo usando os termos: chronic non-cancer pain, pain management, aged e COVID-19. Foram encontrados 86 artigos e selecionados 13. Foram incluídos artigos que cumulativamente versavam sobre dor crônica, representavam pesquisa original de natureza clínica e analisavam o impacto da pandemia do COVID-19 na gestão da dor crônica. A preferência foi dada a estudos com participantes com idade igual ou superior a 65 anos. Também foram analisados estudos realizados em adultos sem menção de idade no âmbito do impacto da pandemia do COVID-19 sobre os aspetos que infuenciam a dor crônica e a sua gestão. Apenas um artigo estudou exclusivamente a população idosa. RESULTADOS: A pandemia afetou: i) aumento da intensidade da dor (n=10), alterações no seu tratamento farmacológico e não farmacológico (n=3) e a sua gestão, isto é, a adaptação dos profissionais de saúde e dos doentes (n=1); ii) negativamente a saúde mental: sintomas de estresse e ansiedade/depressão (n=9), distresse psicológico (n=4), isolamento social/solidão (n=6); iii) estilos de vida: atividade física (n=4), qualidade do sono (n=4) e desempenho físico (n=5); iv) redução da qualidade de vida (n=5). Apesar dos resultados heterogêneos, verificou-se o agravamento da dor e saúde mental, alteração dos estilos e qualidade de vida, disrupção dos serviços médicos. CONCLUSÃO: As restrições impostas pela pandemia afetaram vários domínios da dor em curto prazo. A telemedicina surgiu como uma solução adotada, não podendo descurar os entraves na população idosa, como a falta de literacia digital e falta de equipamentos tecnológicos. O desconhecimento do impacto específico da COVID-19 na dor da população idosa sugere mais investigação que incida sobre as consequências em longo prazo, assim como as soluções a adotar de modo a conter lesões ou disfunções nesta população vulnerável. DESTAQUES Agravamento da dor e saúde mental, alteração dos estilos e diminuição da qualidade de vida. A disrupção dos serviços médicos gerados pelo período pandêmico reforça a necessidade de uma abordagem holística e individual na assistência de saúde. Impacto da pandemia na gestão da dor crônica foi pouco explorado em pessoas idosas. Necessidade de mais investigações que incidam sobre as consequências em longo prazo, assim como as soluções a adotar de modo a conter lesões ou disfunções nesta população vulnerável.

Prescription trends at the end of life in a palliative care unit: observational study.

BACKGROUND: Symptomatic control is essential in palliative care, particularly in end-of-life, in which the pathophysiological changes that characterize this last phase of life strengthen the need to carry out an early therapeutic review. Hence, we aim to evaluate the prescribing pattern at a palliative care unit at two different time points: on admission and the day of the patient's death. METHODS: Quantitative, analytic, longitudinal, retrospective and observational study. Participants were adult patients who were admitted and died in a palliative care unit, in Portugal. Sociodemographic, clinical and pharmacological data were collected, including frequencies and routes of administration of schedule prescribed drugs and rescue drugs, from the day of admission until the day of death. RESULTS: 115 patients were included with an average age of 70.0 ± 12.9 years old, 53.9 were male, mostly referred by the Hospital Palliative Care Support Teams. The most common pathology was cancer, mainly in advanced stage. On admission, the median scheduled prescription was seven and "as needed" was three drugs. On the day of death, a decrease of prescriptions was observed. Opioids were always the most prescribed drugs. Near death, there was a higher tendency to prescribe butylscopolamine, midazolam, diazepam and levomepromazine. The most frequent route of drug administration was oral on admission and subcutaneous on the day of death. CONCLUSIONS: Polypharmacy is a reality in palliative care despite specialist palliative care teams. A reduction of prescribed drugs was verified, essentially due less comorbidity-oriented drugs. Further studies are required to analyse the importance of Hospital Palliative Care Support Teams.

Palliative Care in Patients with Advanced Heart Failure: A Systematic Review.

INTRODUCTION: Heart failure is a disease with survival estimates of around 10% after 10 years of the disease. Being a chronic and debilitatingillness, it is important to investigate the potential efficacy of a palliative care approach for these patients. The aim of this study is to systematically review the efficacy of integrating palliative care in patients with advanced heart failure, including the outcomes overall quality of life and well-being, overall symptom burden and possible specific symptoms, hospital admission rates and mortality. MATERIAL AND METHODS: The MEDLINE, Cochrane, EMBASE and CINAHL databases were searched for articles published between January 2010 and December 2020 about palliative care interventions in patients with heart failure. Clinical studies with humans with symptomatic heart failure were included, comparing the integration of palliative care with usual cardiac care. RESULTS: The search protocol resulted in seven eligible studies for review and qualitative synthesis. The overall risk of bias within studies was moderate to high. Most studies demonstrated improvements with the integration of palliative care in terms of quality of life and reduction of admission rates. The evidence to support a significant improvement in overall symptom burden was not so robust among studies. CONCLUSION: Palliative care interventions seem, overall, to be significantly effective in patients with heart failure. Future studies with more rigorous study designs are needed, in order, to further develop the role of palliative care in heart failure patients.

Introdução: A insuficiência cardíaca apresenta estimativas de sobrevivência de cerca de 10% após 10 anos de doença. Tendo em conta que se trata de uma doença crónica debilitante, é importante investigar os potenciais benefícios e eficácia de uma abordagem de cuidados paliativos. Foi objectivo deste estudo rever de forma sistemática a eficácia dos cuidados paliativos destinados a doentes com insuficiência cardíaca avançada, em termos de qualidade de vida, controlo sintomático, admissões hospitalares e mortalidade. Material e Métodos: Pesquisa na base de dados MEDLINE, Cochrane, EMBASE e CINAHL por artigos publicados entre janeiro de 2010 a dezembro de 2020, tendo sido incluídos estudos clínicos em humanos com insuficiência cardíaca sintomática que compararam a integração de cuidados paliativos com a terapêutica padrão. Os outcomes selecionados para extração de dados foram a qualidade de vida, controlo sintomático, internamentos hospitalares e mortalidade. Resultados: O protocolo de pesquisa resultou em sete estudos elegíveis para revisão e análise qualitativa. O risco geral de viés foi considerado moderado a alto. A maioria dos estudos demonstrou uma melhoria com a integração de cuidados paliativos em termos de qualidade de vida e redução de hospitalizações. A evidência de suporte de uma melhoria significativa no controlo sintomático geral não foi tão robusta. Conclusão: Os cuidados paliativos aparentam ser, em geral, significativamente eficazes para doentes com insuficiência cardíaca avançada. É necessária investigação futura, com estudos mais rigorosos, para realçar o papel dos cuidados paliativos nos doentes com insuficiência cardíaca.

The Physician and End-of-Life Spiritual Care: The PALliatiVE Approach.

Spiritual care is universally acknowledged as a cornerstone of palliative care, yet most healthcare professionals find it difficult to address. The present work aims to provide a simple educational tool that may help physicians address spirituality in their clinical practice. We found articles written in both Portuguese and English through PubMed, using the combination of MeSH terms: "Spirituality" and "Palliative Care." The research was complemented by relevant monographs previously known to the authors, consultation of selected references of the main bibliography, and interviews to an experienced spiritual care provider. In order to help physicians to incorporate spiritual care in their clinical practice, a flexible yet standardized approach is long overdue. This is the aim of the PALliatiVE approach, which compiles the literature in a set of 5 attitudes that may aid the clinician in the delivery of spiritual care: Prepare (P), Ask (A), Listen (L), Validate (V), and consult an Expert (E). This approach is based on a synthesis of a broad literature review, which motivated the five-layered approach. There is a significant literature coverage supporting each attitude of this five-layered approach, including at least one randomized control trial or systematic review per attitude. Though still requiring external validation, the PALliatiVE approach can be a guide to the physician on how to provide spiritual care, a practice rooted in compassion and in simply being-with the one who suffers.

Pharmacological Prophylaxis of Venous Thromboembolism in Terminally Ill Patients: A Need or Futility?

The aim of this case is to clarify the need to maintain the terminally ill oncological patients who have had a thrombotic event in the course of their underlying disease under antithrombotic therapy. This case addresses a 63-year-old man with stage IV gastric antrum adenocarcinoma, completely bed-ridden and anticoagulated with subcutaneous enoxaparin for more than a year, following deep venous thrombosis of the left lower limb. After reviewing the literature, it was found that, for end-of-life patients, anticoagulation seems to have little benefit as the main objective is not the extension of life itself, but rather the preservation of the best quality of life through practices that are well established in the relief of suffering.

O presente caso pretende clarificar qual a verdadeira necessidade de manter sob terapêutica anti-trombótica os doentes oncológicos terminais que tiveram um evento trombótico no decorrer da evolução da sua doença de base. O caso em questão aborda um doente de 63 anos com uma neoplasia do antro gástrico em estadio IV, totalmente acamado, hipocoagulado com enoxaparina subcutânea há mais de um ano, no seguimento de uma trombose venosa profunda no membro inferior esquerdo. Após revisão da literatura, constatou-se que em doentes em fim de vida, a anticoagulação parece ter pouco benefício, visto que o principal objetivo não é o prolongamento da vida, mas sim a preservação da melhor qualidade de vida possível através de práticas cuja evidência no alívio do sofrimento está bem documentada.

Animal-Assisted Therapy in Palliative Care.

There are still many cases where traditional medical care does not provide a realistic solution for patients with devastating diseases so other interventions should be adopted. We present a case report of a 76 year-old woman admitted to a Palliative Care unit due to stage IV colon adenocarcinoma, and we describe the contribution of a six-year-old Yorkshire terrier in her symptom management. Animal-assisted therapy can be of great use in palliative care, contributing to the patients' pain management, relief from suffering and improvement of quality of life.

Existem casos em que os objetivos tradicionais dos cuidados médicos não apresentam soluções realistas para curar os doentes que enfrentam doenças devastadoras; devendo outros métodos ser aplicados. Os autores apresentam o caso clínico de uma mulher de 76 anos admitida numa unidade de Cuidados Paliativos devido a um adenocarcinoma do cólon estadio IV, e descrevem o papel que um Yorkshire terrier, de seis anos, teve no controlo sintomático desta doente. A terapia assistida por animais pode ser de grande utilidade quando usada com um objetivo terapêutico em cuidados paliativos, ajudando a reduzir a dor e o sofrimento dos doentes, aumentando a qualidade de vida. A terapêutica assistida por animais pode ser de grande utilidade nos cuidados paliativos, contribuindo para a gestão da dor dos doentes, alívio do sofrimento e melhoria da qualidade de vida.

Episodic Cancer Pain: Patient Reporting, Prevalence, and Clinicodemographic Associations at Initial Cancer Pain Clinic Assessment.

Background: Better understanding of the episodic cancer pain (CP) spectrum, including pains that occur in addition to its conventionally defined breakthrough CP (BTcP) and incident CP (IcP) components, may inform CP assessment and management. This study aimed to determine the prevalence of episodic patient-reported CP and the prevalence and associations of study-defined BTcP (S-BTcP) and IcP (S-IcP) in patients with CP. Methods: In a cross-sectional study at their first CP clinic attendance, participants with CP had the following assessments: Brief Pain Inventory (BPI); Pain Management Index (PMI), with PMI-negative status indicating undertreatment; standardized neuropathic pain component (NPC) status; S-BTcP (no trigger identified) and S-IcP (trigger identified) status, based on a preceding 7-day history of transitory pain flares distinct from background pain, and BPI-Worst or BPI-Now pain intensity ≥ 4. Clinicodemographic variables' association with S-BTcP and S-IcP was examined in logistic regression analyses. Results: Of 371 participants, 308 (83%) had episodic CP by history alone; 140 (37.7%) and 181 (48.8%) had S-BTcP and S-IcP, respectively. Multivariable analyses demonstrated significant (p < 0.05) associations (odds ratios: 95% CIs) for 6 variables with S-BTcP: head and neck pain location (2.53; 1.20-5.37), NPC (2.39; 1.34-4.26), BPI average pain (1.64; 1.36-1.99), abdominal pain (0.324; 0.120-0.873), S-IcP (0.207; 0.116-0.369), and PMI-negative status (0.443; 0.213-0.918). Similar independent associations (p < 0.05) occurred for S-IcP with NPC, BPI average pain, and PMI-negative status, in addition to radiotherapy, S-BTcP, soft tissue pain, and sleep interference. Conclusions: Episodic or transient patient-reported CP flares often do not meet the more conventional criteria that define BTcP and IcP, the principal episodic CP types. Both BTcP and IcP occur frequently and both are associated with a NPC, higher pain intensity, and less opioid underuse in the management of CP. Further studies are warranted to both better understand the complex presentations of episodic CP and inform its classification.

Early Referral to Palliative Care: The Rationing of Timely Health Care for Cancer Patients.

Palliative care in oncology is an interdisciplinary approach, centered on patients and their families, carried out along the course of neoplastic diseases, based on symptom control, assertive communication and shared decision-making. Although clinical guidelines recommend a holistic intervention, early integration of palliative care into traditional oncological treatment, research shows a great delay in referral of patients, restricting palliative care to end-of-life care. Why does there seem to be a rationing of the early referral, sometimes in violation of human dignity? To a large extent it has to do with lack of knowledge, training and education of health professionals about palliative care and the techniques to deal with the process of death and dying. Several studies have demonstrated the benefit of integrating palliative actions into the routine of active cancer treatments, not only in terms of effective control of physical and psychological symptoms, but also in terms of overall quality of life, patient and family satisfaction, health care costs and survival in some cases. It is necessary to take measures that encourage oncologists to obtain further training in palliative care, as a formal, compulsory internship, integrated in their specific training program. This way, a new generation of physicians will surely change the lives of cancer patients, and their families, integrating - without disproportionate rationing - oncology and palliative medicine.

Os cuidados paliativos oncológicos constituem uma abordagem interdisciplinar, centralizada no doente e nas suas famílias, realizada ao longo da trajetória das doenças neoplásicas, alicerçada no controlo de sintomas, na comunicação assertiva e na tomada de decisão compartilhada. Apesar de as normas de orientação clínica aconselharem uma intervenção holística, integrando precocemente os cuidados paliativos no tratamento oncológico tradicional, a investigação demonstra um grande atraso na referenciação dos doentes, restringindo os cuidados paliativos no fim de vida. Por que razão parece existir um racionamento da referenciação precoce, atentatório da dignidade humana? Em grande parte, é por falta de conhecimento, treino e educação dos profissionais de saúde sobre os cuidados paliativos e as técnicas para lidar com o processo de morrer e a morte. Vários estudos demonstram o benefício da integração de ações paliativas na rotina dos tratamentos oncológicos ativos, não só a nível do controlo eficaz de sintomas físicos e psicológicos, mas a nível da qualidade de vida global, da satisfação do doente e da família, dos custos dos cuidados de saúde e também da sobrevida, em alguns casos. É necessário tomar medidas que encorajem o oncologista a obter mais formação em cuidados paliativos, como um estágio formal, obrigatório, integrado no seu internato de formação específica. Deste modo, uma nova geração de médicos mudará seguramente a vida dos doentes com cancro, e suas famílias, integrando ­ sem racionamento desproporcionado ­ oncologia e medicina paliativa.

Chronic Pain Education in Portugal: Perspectives from Medical Students and Interns.

INTRODUCTION: The International Association for the Study of Pain advocates a mandatory curriculum on chronic pain in medical schools. The objective of this study was to assess the opinions of final year medical students and interns about chronic pain education in eight Portuguese medical schools. MATERIAL AND METHODS: Cross-sectional study. Online questionnaire (30 questions; voluntary and anonymous responses) available in the first quarter of 2016. RESULTS: A total of 251 responses were received from 142 finalists and 109 interns (women 72.9%; 25.3 ± 1.6 years). Pain is a vital sign (92.4%), but 18.7% only assessed pain if the patient complained of it. Pain self-assessment scales were known (87.2%), but the hetero-evaluation was not (70.9%). Pain was not assessed regularly because patients may not express pain; lack of time; short duration of consultations. Education was insufficient on opioids (78.1%), pathophysiology and treatment of pain (66.1%) and interviewing patients with pain (67.7%); it lasted 1 to 10 hours (median). Respiratory depression was the most worrying effect of opioids (56.2%). The risks of opioids outweigh the clinical benefit (33.5%). DISCUSSION: Education on chronic pain is scattered, unstructured and optional. More education is required in medical schools (98.4%). It should occur in year 5 and last more than 15 hours. Clinical stages are advised in chronic pain clinics. CONCLUSION: There is a need for improvement in the medical undergraduate curricula so that young doctors develop competencies to adequately control pain and fight the avoidable suffering of their patients.

Introdução: A Associação Internacional para o Estudo da Dor defende um curriculum mandatório sobre dor crónica nos cursos de Medicina. Foi objectivo deste estudo conhecer a opinião dos estudantes finalistas de Medicina e dos internos do ano comum sobre o ensino da dor crónica nas oito escolas médicas Portuguesas.Material e Métodos: Estudo quantitativo. Questionário electrónico (30 questões), com respostas voluntárias e anónimas; disponível no primeiro trimestre 2016.Resultados: Houve 251 respostas provenientes de 142 finalistas e 109 internos (mulheres 72,9%; idade 25,3 ± 1,6 anos). A dor é um sinal vital (92,4%); mas 18,7% apenas a avaliava caso o doente se queixasse. As escalas de auto-avaliação da dor eram conhecidas (87,2%) e as de hétero-avaliação não (70,9%). A dor não era avaliada porque o doente não manifestava dor; falta de tempo; consultas de duração curta. A formação foi insuficiente sobre opioides (78,1%), fisiopatologia e tratamento da dor (66,1%) e como entrevistar o doente com dor (67,7%); durou 1 a 10 horas (49,8%). A depressão respiratória por opioides é preocupante (56,2%). O risco de usar opioides é superior ao benefício clínico (33,5%).Discussão: O ensino da dor crónica é disperso, pouco estruturado e opcional. Para 98,4% da amostra é relevante haver mais educação sobre dor crónica. Esta deve ocorrer no quinto ano do curso médico, com mais de 15 horas. São aconselhados estágios em consultas de dor crónica.Conclusão: São necessárias mudanças nos curricula pré-graduados para que os futuros médicos desenvolvam competências e combatam o sofrimento 'evitável' dos seus doentes.

Cancer-Related Pain: A Longitudinal Study of Time to Stable Pain Control and Its Clinicodemographic Predictors.

CONTEXT: Multidimensional assessment is pivotal in managing cancer-related pain. OBJECTIVES: The objectives of this study were to determine time to stable pain control (SPC) and identify its baseline clinicodemographic predictors in patients with cancer pain. METHODS: This is a prospective longitudinal study of patients attending a cancer pain clinic. Scheduled clinic attendances and weekly investigator-led phone calls enabled monitoring of patients' daily pain diary, opioid use, and other analgesic interventions. Baseline clinicodemographic variables were examined in survival analyses, which included the construction of accelerated failure time models with time ratios [TRs, (95% CIs)], based on time to SPC (pain intensity ≤3 and <3 breakthrough opioid doses over three consecutive days) for variable categories. RESULTS: Of 319 participants, 22 died before achieving SPC and were censored in the survival analysis. The median survival time (95% CI) to SPC was 22 (19-25) days. In multivariable analysis, compared to their respective reference categories, female sex (P = 0.001), substance abuse (P < 0.001), a neuropathic pain component (P < 0.001), and use of ≥1 adjuvant analgesic (P = 0.022) each had TRs > 1 (1.03-2.54), whereas soft tissue pain (P < 0.001) had a TR = 0.71 (0.62-0.82), reflecting longer and shorter time to SPC, respectively. CONCLUSION: SPC is achievable for most patients with cancer pain. Recognition of strong predictors of time to SPC, such as substance abuse, a neuropathic pain component, soft tissue pain, and current use of adjuvant analgesia, may help to triage care services based on therapeutic need and guide analgesic interventions.